OFFICE POLICIES & GENERAL INFORMATION AGREEMENT TO PROVIDE COUNSELING SERVICESOffice Policies • March 1st, 2019
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.
This is an agreement between the office of Aaron C. Polk, D.D.S. Dentistry and the Patient/Debtor named on this form.Office Policies • November 19th, 2020
In this agreement, the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments are credited. The words “we,” “us,” and “our” refers to the office of Aaron C. Polk, D.D.S. Dentistry. By executing this agreement, you are agreeing to pay for all services that are received.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies • September 16th, 2016
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re- scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies • February 1st, 2011
Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES ANGIE LEWIS, M.S.Office Policies • March 23rd, 2018
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law (See HIPAA Attachment).
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies • April 1st, 2011
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.
OFFICE POLICIESOffice Policies • December 17th, 2018
All co-payments and account balances are due in full at the time service is provided in office. We accept cash, Visa, MasterCard, American Express, Discover, and Care Credit.
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES ANGIE LEWIS, M.S.Office Policies • April 3rd, 2018
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law (See HIPAA Attachment).
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICESOffice Policies • September 24th, 2016
This form provides you, the client, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
OFFICE POLICIESOffice Policies • October 17th, 2021
Welcome to the counseling and coaching practice at Resolve Counseling Center. This document contains important information about professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting.
Office Policies Financial AgreementOffice Policies • August 4th, 2020
Welcome! Thank you for selecting us as your dental health care provider. Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and as comfortable as possible throughout our relationship. We encourage you to ask questions and to be involved in treatment decisions. This includes understanding your treatment plan as well as our financial policy. For your knowledge, our Financial Policy is outlined below:
